Seadtion and pain control in Dentistry

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Seadtion and pain control in Dentistry

  1. 1. Sedation and Pain Control in Dentistry Iyad Abou Rabii DDS. OMFS. DU. MRes. PhD
  2. 2. Page  2 Welcome BienvenueWillkommen Benvenuto Bienvenida yôkoso tervetuloa welkom
  3. 3. Page  3 Please mute Your cell!
  4. 4. Page  4 Are we doing our best to help our patients to get red of their pain? Can we do more?
  5. 5. Page  5 DATE DurationSlides 49 1 hour Let us try to answer this 16/11/2010
  6. 6. Page  6 Yes or No The Dentist is the best judge of pain. A person with pain will always have obvious signs such as moaning, abnormal vital signs, or not eating. Addiction is common when opioid medications are prescribed. Morphine and other strong pain relievers should be reserved for the late stages of dying. Morphine and other opioids can easily cause lethal respiratory depression. Pain medication should be given only after the resident develops pain.
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  19. 19. Page  19 Yes or No The Dentist is the best judge of pain. A person with pain will always have obvious signs such as moaning, abnormal vital signs, or not eating. Addiction is common when opioid medications are prescribed. Morphine and other strong pain relievers should be reserved for the late stages of dying. Morphine and other opioids can easily cause lethal respiratory depression. Pain medication should be given only after the resident develops pain. No No No No No No
  20. 20. Page  20 Sarah has presented at your office reporting severe pain that kept her awake all night. She denies any contraindications to NSAIDs. After examination, you find the patient is suffering from irreversible pulpitis with acute apical periodontitis, and a root canal procedure is initiated. This patient may will experience some post-appointment pain due to continued inflammation of the periapical tissues. Sarah has presented at your office reporting severe pain that kept her awake all night. She denies any contraindications to NSAIDs. After examination, you find the patient is suffering from irreversible pulpitis with acute apical periodontitis, and a root canal procedure is initiated. This patient may will experience some post-appointment pain due to continued inflammation of the periapical tissues.
  21. 21. Page  21 • NO apparent factors for odontogenic pain, • No consistent relief of pain by local anesthetic. • Bilateral pain or multiple painful teeth. • Pain that occurs with a headache. • Increased pain associated with palpation of trigger point or muscles, emotional stress, physical exercise, head position, etc. • NO apparent factors for odontogenic pain, • No consistent relief of pain by local anesthetic. • Bilateral pain or multiple painful teeth. • Pain that occurs with a headache. • Increased pain associated with palpation of trigger point or muscles, emotional stress, physical exercise, head position, etc. • Presence of etiologic factors for an odontogenic origin, (e.g. Caries, leakage of restorations, trauma, fracture). • Responsive to dental treatment • Pain reduction by local anesthetic. • Unilateral and localized pain. • Sensitivity to temperature., percussion , and digital pressure. • Presence of etiologic factors for an odontogenic origin, (e.g. Caries, leakage of restorations, trauma, fracture). • Responsive to dental treatment • Pain reduction by local anesthetic. • Unilateral and localized pain. • Sensitivity to temperature., percussion , and digital pressure. Pain in dental clinic Non-odontogenicNon-odontogenicOdontogenicOdontogenic
  22. 22. During Intervention Preoperative Pain Post-Operative Pain Control Strategy
  23. 23. Pain Preoperative During Intervention Post-Operative Pain Control Strategy
  24. 24. Pre-operativePre-operative  Oral Sedation  Preoperative Analgesics  Oral Sedation  Preoperative Analgesics SCENE Pain Control Strategy
  25. 25. During the InterventionDuring the Intervention • IV Sedation • Nitrous Oxide • Local Anesthesia • IV Sedation • Nitrous Oxide • Local Anesthesia SCENE Pain Control Strategy
  26. 26. Post-opertaivePost-opertaive • Analgesic Prescription • Opioids • Non-opioids • Analgesic Prescription • Opioids • Non-opioids SCENE
  27. 27. Pre-operative procedures
  28. 28. Page  28 Oral Sedation  Happy pills  Before the appointment,
  29. 29. Page  29 Oral Sedation : Drugs Used  Anti-Anxiety Pills (Benzodiazepines or "Benzos")  "Sleeping pills" (Barbiturates)  Antihistamines
  30. 30. Page  30 Preoperative Analgesics  Pre-treating patients with NSAID's delays the onset of post-operative pain and reduces its magnitude when it does occur.  Pretreatment with acetaminophen is not effective.  Aspirin in not used for this purpose since it can increase bleeding.
  31. 31. During Surgical or Dental Intervention
  32. 32. Page  32 IV Sedation  Anti-anxiety variety, is administered into the blood system during dental treatment  Safe  The drugs which are usually used for IV sedation are not painkillers
  33. 33. Page  33 IV Sedation : Drugs Used – benzos – Barbiturates(sleep-inducing drugs) – Opioids – Propofol
  34. 34. Page  34 IV Sedation : Caution and Contraindication – contraindications include pregnancy, known allergy to benzos, alcohol intoxication, CNS depression, and some instances of glaucoma. – Cautions include psychosis, impaired lung or kidney or liver function, and advanced age. Heart disease is generally not a contraindication
  35. 35. Page  35 Nitrous Oxide  Referred to as laughing gas or sweet air  Useful for fearful patients as well as young children  After the patient is relaxed and sedated, the dentist can comfortably give the injection or proceed to dental treatment
  36. 36. Page  36 Nitrous Oxide: Contraindications – Some chronic obstructive pulmonary diseases – Severe emotional disturbances or drug-related dependencies – First trimester of pregnancy – Treatment with bleomycin sulfate
  37. 37. Page  37 Local Anesthesia
  38. 38. Page  38 Local Anesthesia : Choice of Drug and Technique  1-According to procedure (expected duration, the surgical procedure tissue’s implication)  2- According to the patient physiological and pathological situation
  39. 39. Page  39 Failure of Anesthesia Pathological causes Psychological causes Anatomical causes Operator dependent
  40. 40. Page  40 Failure of anesthesia  Psychological causes of failure  Pathological causes of failure of anesthesia – Factors precluding access – Inflammation
  41. 41. Page  41 Failure of anesthesia  Anatomical causes of failure of anesthesia – Soft-tissue analgesia is more easily obtained, needing a lower degree of penetration of solution into nerve bundles, than does analgesia from pulpal stimulation. – A numb lip does not indicate pulpal anaesthesia. – Accessory nerve supply – Barriers to anaesthetic diffusion – Dense compact bone can prevent a properly given infiltration from working. Counter by using intraligamentary or regional LA.
  42. 42. Page  42 Accessory nerve supplies
  43. 43. Page  43 Failure of anesthesia  Operator dependent causes of failure of Anesthesia – Choice of LA – Poor technique • inadequate volume of LA. • Injection into a muscle (will result in trismus which resolves spontaneously). • Injection into an infected area (which should not be done anyway as this risks spreading the infection). • Intravascular injection; clearly of no analgesic benefit. Small amounts of intravascular LA cause few problems.
  44. 44. Page  44 Management of failure of Anesthesia  A technique suggested for patients who have experienced local anesthetic failure in the mandible is
  45. 45. Page  45 Failure Management : Mandible
  46. 46. Page  46 Management of failure of Anesthesia  A technique suggested for patients who have experienced local anesthetic failure in the maxilla is
  47. 47. Page  47 Failure management : Maxilla
  48. 48. Page  48 Important general points  Nerve trunks Thickness  In nerve trunks autonomic functions are blocked first, then sensitivity to temperature, followed by pain, touch, pressure, and motor function.  Soft tissue anesthesia is reached before the levels needed for pulpal anesthesia, which takes several minutes and will wear off first
  49. 49. Post-operative procedures
  50. 50. Page  50 Analgesic Prescription  Ceiling effect – The term ceiling effect has two distinct meanings, referring to the level at which an independent variable no longer has an effect on a dependent variable – In case of Analgesics, a ceiling effect in treatment, is pain relief by some kinds of Analgesics drugs, which have no further effect on pain above a particular dosage level
  51. 51. Page  51 Types of Analgesics – Opioid • Morphine • Tramadol – Non-opioids • acidic analgesics – Salicylic acid derivatives – Acetic acid derivatives – Propionic acid derivatives – Anthranilic acid derivatives • non-acidic analgesics – Aniline derivatives – Pyrazolone derivatives
  52. 52. Page  52 Types of Analgesics
  53. 53. Page  53 Types of Analgesics
  54. 54. Non-odontogenic Pain
  55. 55. Page  55 Trigeminal Neuralgia – Non-analgesic drug (Carbamazepine) give excellent results in the treatment of Trigeminal Neuralgia – Dose • 100 mg twice daily • No improvement: the dose is increased to 200 mg four time a day • No improvement : Dose can be augmented until 1600 mg a day with (monitoring of plasmatic concentration of the drug should be achieved regularly) – If with such dose there is no improvement then Phenytoin is used (150 to 300 mg daily)
  56. 56. Page  56 TMJ Pain  Diazepam has both sedative and muscle relaxant effects, so it is helpful if the origin of the trismus is psychotic  In other cases the use of Paracetamol 250 mg in combination with Chlorzoxzson (muscle relaxant ) 300 mg is recommended 4 times daily.
  57. 57. Page  57 atypical facial pain  The use of Tricyclic antidepressant looks helpful (Amitriptyline)  Anyway the prescription of such drugs should not be done by a dentist
  58. 58. Page  58 1 2 3 Long acting local anesthetics Precise estimation of the pain Use the right analgesic Conclusion 6 5 4 Profound local Anesthesia Removal of the cause Accurate Diagnostic
  59. 59. Page  59 Pain management schema
  60. 60. Page  60 What about Sarah ?
  61. 61. Page  61
  62. 62. Page  62 Thank you for your attention! Any Questions?
  63. 63. Page  63 Contact Details Dr. Iyad Abou Rabii +33612198442 +966532758000 www.facebook.com/iarabii www.Twitter.com/iarabii www.Scribd.com/iyad abou rabii Email iyad@wanadoo.fr Iyad.abou.rabii@qudent.edu.sa

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